Provider Demographics
NPI:1932355534
Name:WALTERS, FRED IRVIN JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:IRVIN
Last Name:WALTERS
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1434 PARKER DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-1942
Mailing Address - Country:US
Mailing Address - Phone:601-649-3335
Mailing Address - Fax:601-426-6318
Practice Address - Street 1:1434 PARKER DRIVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-1942
Practice Address - Country:US
Practice Address - Phone:601-649-3335
Practice Address - Fax:601-426-6318
Is Sole Proprietor?:No
Enumeration Date:2008-08-14
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3056981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice